Healthcare Provider Details

I. General information

NPI: 1306186234
Provider Name (Legal Business Name): WHITE RIVER ACADEMY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2013
Last Update Date: 10/16/2025
Certification Date: 10/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 W 100 S
DELTA UT
84624-9238
US

IV. Provider business mailing address

275 W 100 S
DELTA UT
84624-9238
US

V. Phone/Fax

Practice location:
  • Phone: 435-659-2368
  • Fax: 435-213-2810
Mailing address:
  • Phone: 435-659-2368
  • Fax: 435-213-2810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: JUSTIN EDWARD NIELSON
Title or Position: PROGRAM DIRECTOR
Credential:
Phone: 435-659-2368